Monitor Mondays

Listen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!In today's episode, Mary explains the importance of Coding Essentials for Laboratories.  Listen in to find out why this textbook could be a great edition to add to your essential library.

Stranger than fiction are the reports coming from providers complaining of inconsistent and often contradictory reasons given for claim denials, leading to recoupment and the possibility of Medicare revoking privileges of participation in federal health programs – and this at a time of shrinking margins, rising inflation, budget cuts, and staff shortages. Little wonder that America’s hospitals, health systems, and physician practices are feeling the pain.However, during the next special news edition of Monitor Mondays, you will not only hear field reports from our distinguished and highly respected panelists, but also gain the benefit of practical guidance in traversing the treacherous audit terrain.And, as a special added feature, Monitor Mondays will conduct an exclusive roundtable on the contentious and controversial 340B drug discount program. Substituting for the program’s executive producer and program host, Chuck Buck, will be Dr. John K. Hall.Other segments will include these instantly recognizable br

Denials by payors for hospital claims continue to mount. Hospitals should take every opportunity to have a denial overturned – and an oft-neglected method is with a peer-to-peer call for a concurrent denial. A physician advisor can dedicate time and resources to accomplish it, but what do you do when the payor insists on only speaking with the attending physician?Since this is a recurring issue with providers and auditors, Monitor Mondays has asked Dr. Chris Shearer to report on this untenable issue – and to offer advice to other providers.Other segments will include these instantly recognizable broadcast segments:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.Risky Business: Healthcare attorney David Glaser, shareholder in the l

Listen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!In today's episode, Mary explains the importance of Coding Essentials for Infusion & Injection Therapy Services.  Listen in to find out why this textbook could be a great edition to add to your essential library.

Nearly $3 billion in expected recoveries have surfaced in the spring 2022 Semiannual Report to Congress by the U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG). As reported by RACmonitor’s Mark Spivey, the OIG report also provides an overview of the watchdog’s activities from Oct. 1, 2021 through March 31, 2022. During the next live edition of Monitor Mondays, providing comment and context to the report, which was published Monday, June 6, will be prominent healthcare attorney Andrew “Drew” Wachler, a longtime OIG observer and the managing partner at Wachler and Associates. Other segments will include these instantly recognizable broadcast segments: The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors.  SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the S

The 2022 audit landscape is rife with pitfalls and quicksand, trapping unsuspecting hospitals, health systems, and physician practices into a financial quasi-death spiral.And now, there’s another major disruptor: Condition Code 44, which continues to confound providers and revenue cycle professionals. Even though the Recovery Audit Contractors (RACs) have been held at bay, there are new audits targeting the proverbial low-hanging fruit, ripe for the picking. Complicating an already dismal radar screen is the return of the Inpatient-only List, bringing enormous confusion and creating the perfect setup for more audits.Following news updates from a cadre of venerable Monitor Mondays panelists, a grouping of experts will regather around the virtual roundtable during the next edition of the live Internet broadcast, where, led by Dr. John K. Hall, attorney and physician, they will offer advice, answer your questions in real time, and forecast upcoming audits.Preceding the roundtable, “Tales from the Audit Trail,” w

Listen to Mary's Bookclub, where Mary summarizes the books you can find at the MedLearn online bookstore!In today's episode, Mary explains the importance of Coding Essentials for Respiratory Therapy/ Pulmonary Function.  Listen in to find out why this textbook could be a great edition to add to your essential library.

The 2 MN Rule has been with us for several years but there still is confusion about what qualifies as inpatient.Condition Code 44 has been the corrective approach to inpatient status errors despite CMS’ warning that Condition Code 44 should not be used as a substitution for inadequate utilization management processes. Condition Code 44 can serve as a reflection that the utilization process is being monitored and claims are billed compliantly. Dr. John Zelem will review the crucial four requirements for Condition Code 44 compliance.Other segments will include the following:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.Risky Business: Healthcare attorney David Glaser, shareholder in the law o

Johnson & Johnson, along with Gilead, are among the most recent pharmacy giants that have joined the list of others that are imposing restrictions on 340B drug price discounts to 340B hospitals. The latest information comes from a recent study conducted between December 2021 and March 2022 that reveals 16 other major pharmacies are flaunting the law – and their actions have doubled.Reporting the lead story during the next live edition of Monitor Mondays will be Maureen Testoni, president and CEO of 340B Health. Testoni, a popular guest, is expected to report that consequently, the damage will continue to grow – until these pharmaceutical manufacturers are forced to restore the discounts and obey the law.Other segments to be featured during the broadcast will include the following:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).SDoH Report: Tiffany Ferguson, a subject matter expert on

2010 does not seem that long ago. It’s hard to believe we’re at Monitor Mondays broadcast No. 500 since then.But then again, let’s look at all we’ve seen change. Medicare started out with a one-midnight expectation for inpatient reimbursement. Then the Recovery Audit Contractors (RACs) moved in, showed us all the errors of our ways, and demonstrated that unrestrained denials could overwhelm the appeal system.Then we got the two-midnight rule, which, oddly enough, seemed to make sense. It carved off a bunch of inpatient stays, but also curtailed denials. Then we saw the phase out of the inpatient-only list. But wait – the Centers for Medicare & Medicaid Services (CMS) reversed course and decided not only to keep the inpatient-only list, but to add stuff back on to it. The one constant since 2010, via more than 500 live broadcasts,has been Monitor Mondays, bringing cutting-edge analysis of regulatory changes and providing reliable information for you to meet payor challenges. We’re looking forward to anothe

Like fine wine, problem lists age very well. Too well, in fact.Such lists can remain in place for months, even years, without being updated. And questions can lead to conflicts and errors.Too often, problem lists simply languish, with unchanged patient encounter information. Moreover, even when a problem does appear on the problem list, it doesn’t necessarily signal that the provider addressed the issue during the patient encounter.During the next live edition of Monitor Mondays, Dr. Andrew Markiewitz, a physician advisor and member of the RACmonitor editorial board, will delve deep into the root causes of problems in the problem list.Other segments will include the following:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of heal

With the growth of Medicare hospice services comes expanded oversight on claims and care quality. The U.S. Department of Health and Human Services (HHS) Office of Inspector General (OIG) has initiated a nationwide audit of hospice claims on the heels of multiple in-depth audits of such facilities. Unified Program Integrity Contractors (UPICs) and Medicare Administrative Contractors (MACs) have joined the hunt in recent weeks, putting all hospices on notice that vigilant compliance measures are essential. At the same time, there have been increased survey frequency and expanded sanction risk targeting these providers – and all of this will be part of the coverage of our lead story during the next Monitor Mondays broadcast.  Other segments will include the following:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs). SDoH Report: Tiffany Ferguson, a subject matter expert on the social determin

How is one major hospital system reducing observation hours?Listen to the next live edition of Monitor Mondays to find out; that’s when Mary Beth Pace will return, by popular demand, to continue her compelling discussion on how she and her team at Trinity Health are taking steps to reduce the volume of observation hours. With her laser focus on patient care, Pace will report on how the Centers for Medicare & Medicaid Services (CMS) two-midnight rule, implemented in October 2013, continues to be misinterpreted by some insurance companies to their advantage, further obfuscating patient status determination.Pace will also discuss what should be done with payers who dictate billing status, regardless of the care provided.Other segments will include the following:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).  SDoH Report: Tiffany Ferguson, a subject matter expert on the social determina

What are your observation volumes doing to your bottom line? How much care do these patients get compared to your inpatients?If your facility is like most facilities, the billing status does not dictate the care provided; it just dictates the reimbursement you can expect to obtain. Worse yet, it does not leverage the patient’s insurance benefits correctly. Join us during the next live edition of Monitor Mondays as Mary Beth Pace reports on what should and could be done with the insurance companies that are dictating billing status, no matter the care provided to their card holders. Listen and learn as Pace discusses how her organization is taking on this mission to care for patients.Other segments reported by an array of trusted subject matter experts will include the following:SDoH Report: Tiffany Ferguson, a subject matter expert on the social determinants of health (SDoH), will report on the news that’s happening at the intersection of healthcare regulations and the SDoH.Risky Business: Healthcare attorney

The latest essential webcasts by RACmonitor are “Payer Contracts: Keys to Increasing Your Leverage,” led by Tiffany Ferguson and Marie Stinebuck, and the perennially popular on-demand webcast, “Implantable Device Credit Reporting and Outlier Payments: Audits Reviving up in 2022.” Both are given high marks in this current episode of Front and Center.Great topics. Great analysis. More great educational opportunities now await you. So now get everyone on your team Front and Center.Use code FRONTANDCENTER  for 15% off your RACmonitor webcast purchases.

Too many times, and in too many cases, providers are being subjected to flaws in methodologies and calculations used by auditors that lead to recoupment demands and other penalties.Aided by ambiguously written rules from the Centers for Medicare & Medicaid Services (CMS), unscrupulous auditors are often able to pounce on unsuspecting providers, wreaking havoc on revenues and human resources. The toll can be devastating. Monitoring on a daily basis providers’ concerns and questions, RACmonitor and Monitor Mondays both report on these cases, bringing to light auditors’ errors of commission and omission.During the next live edition of Monitor Mondays, trusted subject matter experts will report on the following:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Recovery Auditors (RAs).The Whistleblower Report: Famed whistleblower attorney Mary Inman will report that the U.S. Department of Justice (DOJ) is joining a

The threat of medical necessity denials of coverage – a mainstay of insurers to avoid paying claims – requires providers to have administratively costly utilization management (UM) departments. Good physician documentation and educated UM processes are highly effective in getting such denials overturned.  However, there are also so-called “technical denials,” in which real or alleged provider lapses in the prior authorization process arise that can be hard, or even impossible, to overcome.  During the next live edition of Monitor Mondays, Marvin Mitchell, director of case management and social services at San Gorgonio Memorial Hospital in Banning, Calif., will report on this emerging audit trap, and also discuss how to avoid or overcome these crafty insurer maneuvers.Other segments reported by an array of trusted subject matter experts will include the following:The RAC Report: Healthcare attorney Knicole Emanuel, partner at the law firm of Practus, will report the latest news about auditors, including the Re

Like the insidious omicron variant of the COVID-19 virus, America’s healthcare auditors are, in many cases, auditing claims with complete abandon, forsaking rules created specifically to curb payor abuse. And driven by profit motive, many commercial payors, in fulfilling their corporate mandate to manage risk and save money, find the low-hanging fruit to be ripe for harvesting.While the Centers for Medicare & Medicaid Services (CMS) continues to punish providers for claims submitted with errors of omission, the same disciplinary action is infrequently demonstrated publicly against payors behaving badly. It’s little wonder, in today’s highly regulated healthcare environment, that the audit landscape is fraught with peril for providers. Most notably, Medicare Advantage (MA) plans can tend to skirt the rules and audit records recklessly.For the latest national updates on auditing gone awry, listen to the next live edition of Monitor Mondays.Learn from an array of trusted subject matter experts who will repor

As the country approaches the two-year milestone after when schools and public places first closed because of the coronavirus pandemic, there are reports circulating that readmission denials are occurring for patients with COVID-19. As the pandemic spread,  telehealth gained a foothold in America’s healthcare system, but that too is being subjected to audits. Medicare Advantage (MA) plans can tend to skirt the rules and audit records recklessly. It's a topic that needs to be followed closely. So for the latest national updates on auditing gone awry, listen to the next live edition of Monitor Mondays.  As always, an array of trusted subject matter experts will report on the auditing landscape, and how to protect your facility from recoupment of revenue: The Whistleblower Report: Famed whistleblower attorney Mary Inman will report on the$260 million settlement that pharmaceutical manufacturer Mallinckrodt ARD LLC has agreed to pay to resolve allegations it violated the False Claims Act by underpaying Medic

Medicare initiated the prior authorization process for select services for dates of service on or after July 1, 2020. Yet when “prior auths” are in the wrong hands, a potential crisis looms. And that’s apparently the case involving Recovery Auditors (RAs) and some providers.  In the FAQ related to the prior authorization process released by the Centers for Medicare & Medicaid Services (CMS), it states that generally, claims that have a provisional affirmation decision will not be subject to additional review; however, CMS contractors, including Uniform Program Integrity Contractors (UPICs) and Medicare Administrative Contractors (MACs) may perform reviews based on evidence of potential fraud or gaming, and the Comprehensive Error Rate Testing (CERT) contractor may review a random sample for the purposes of estimating the Medicare improper payment rate. The RAs, however, are not listed as audit contractors allowed to audit these claims – nor should they be. So why are providers receiving audit requests for